Elias Kass ND
Elias Kass, ND (formerly LM, CPM) is a naturopathic physician and former licensed midwife in private practice in Seattle, WA. He graduated from Bastyr University in 2010. After five years of dual naturopathic and midwifery practice, he now focuses on pediatric primary care, with an additional specialty in breastfeeding medicine and infant feeding. He is a strong advocate for immunizations at all stages, as well as proper use of car seats!
A few months ago I gave a lunchtime webinar to a regional work group focused on antimicrobial stewardship. Vaccines are an important component of antimicrobial stewardship: preventing infections means you don’t need to treat them, so there’s no better way to reduce antibiotic prescribing than by not needing to prescribe them at all.
At the end of the presentation, a provider thanked me and said, “This is all really great information, but we don’t have time to talk to our patients the way you do – do you have a handout or something we could give out?”
Nothing takes the place of a relationship in counseling about vaccines.
Relationships take time.
And in our healthcare system, time is money. Time spent counseling on vaccines is time that a provider is not providing other services – billable services.
Why is vaccine counseling not considered billable? After all, smoking cessation is billable. The Affordable Care Act even requires it be covered for adolescents and adults. (If your patient is a child, and their parent is smoking, your counseling the parent to stop smoking to protect the child is not billable. This is a glaring oversight, since smoking has direct impact on babies and children, including increased risk for SIDS and asthma.)
There are many parallels between smoking and vaccine hesitancy. Nobody thinks that handing someone a pamphlet is going to be effective in convincing someone to quit smoking, let alone facilitating the quitting. Nobody thinks that people just haven’t heard that smoking is unhealthy. Everyone has a basic understanding that smoking is dangerous, just like everyone has a basic understanding that infectious diseases are dangerous. Many people think that they will not be affected – their great Uncle Joe smoked and ate fried food until the day he died at 89! – but they understand the premise. Lack of information is not why people smoke. People smoke because of the feelings, because of the social experience, because of emotions and identity and addiction. They get something out of smoking.
Similarly, while information is helpful in understanding the value of vaccines, lack of information is rarely the sole component of hesitancy. Rather, anxiety and fear and a host of other emotions are involved in the decision. And, like smoking, deciding to vaccine is not a single decision or a single moment. When someone quits smoking, they need to decide in every moment not to smoke. That gets easier as time goes by and as nicotine withdrawal wanes, but it’s still an active decision. People need to build a new identity around a new activity. They need to develop their narrative for why they don’t smoke and why they do something else instead, so they can continue to tell themselves that story when they are wondering why they’re not outside with their friend, or why they’re not going to bum a cigarette after a rough day at work. Vaccinating is an ongoing decision. At each visit a parent needs to be willing to go ahead with the vaccines, even knowing the baby will cry or the older kid will be afraid. Online they need to be willing to stand up to the anti-vaccine memes in their timeline and the anti-vaccine fear mongering in their Facebook groups. They need to be able to withstand the pressure from their friends or family, telling them they are harming their children by vaccinating.
If organizations are serious about wanting to improve immunization rates among their patient populations, they need to support clinicians’ time in the room developing relationships and having conversations about vaccines. If we can get paid for freezing off a wart, removing a skin tag, or evaluating a cough, we should be able to get paid for doing the work to move parents from hesitancy to confidence, and laying the groundwork for immunization. A single case of measles costs $140,000 to contain, not to mention the costs to care for the affected individual (and the costs of the infections experienced after measles demolishes the individual’s immune memory). Given that the MMR vaccine costs between $25-75, it seems like there should be some room in there to invest in moving parents towards the vaccine, rather than leaving them vulnerable to infection.
How do you get paid for these conversations?
If the immunizations are given, the counseling is included in the counseling and administration codes. Counseling includes reviewing and discussing the vaccine information statement (VIS), the risks and benefits of the specifics vaccines, contraindications for the vaccines, and addressing any questions.
If the vaccine is not given, then there needs to be a separate code in use.
Counseling and administration (90460-90461) is based on vaccine component, which is to say, each disease covered by the vaccine or toxoid. For example, DTaP has three components, diphtheria, tetanus and pertussis. 90460 refers to the first component of each vaccine, and 90461 to each subsequent component, so when you code for DTaP, you code:
- 90700 – DTaP (Daptacel, Infanrix)
- 90460 – first component counseling and administration
- 90461 – second component counseling and administration
- 90461 – third component counseling and administration
Some billing interfaces phrase this as a “90461 x 2 units”
If you give another vaccine, you start over with the component count. For example, if you give DTaP and IPV, you would code:
- 90700 – DTaP (Daptacel, Infanrix)
- 90460 – first component
- 90461 – second component
- 90461 – third component (another ‘subsequent’ component)
- 90713 – inactivated polio (IPV) (IPOL)
- 90460 – first component
Administration without counseling (90471-90474) is based on vaccines. For example, if you gave rotavirus (oral), DTaP-Hib/IPV, and PCV13, you would code
- 90670 – PCV13 (Prevnar)
- 90471 – first vaccine administration
- 90698 – DTaP-Hib/IPV (Pentacel)
- 90472 – second vaccine administration
- 90680 – rotavirus vaccine (Rotateq, Rotarix)
- 90472 – third vaccine administration (another ‘subsequent’ vaccine)
Note that there may be payer-based differences, especially Medicaid, Medicare, and those qualifying for Vaccines for Children. In Washington State, the Washington Vaccine Association instructs providers in how to bill for vaccines acquired through the universal VFC program.
Of note, Medicaid in Washington State does not pay any counseling component — providers bill the vaccine product with the modifier SL and are paid somewhere between $6 and $19 for administration only. There is no separate administration code for pediatric patients. For the example above, the provider would code:
- 90670,SL – PCV13 (Prevnar)
- 90698,SL – DTaP-Hib/IPV (Pentacel)
- 90680,SL – rotavirus vaccine (Rotateq, Rotarix)
Be sure the vaccine product has a price attached, since they will not reimburse more than was charged.
But what if you don’t give the vaccine? Sometimes we counsel for months or years before a parent agrees to immunize their child. How do we get compensated for the time we spend counseling?
E&M (evaluation and management) based on time
You can bill for these conversations when 50% or more of the visit is spent in counseling.
You are probably familiar with this grid to determine the appropriate coding level for a particular visit. Note the time following each time in the first column of each grid. This is the time traditionally associated with that level of visit. If you spend more than 50% of that time counseling (or coordinating care), you can bill based on time. That means 25 minutes spent counseling an existing patient on vaccines can be billed at a level of 99214.
|99201 10||Straight||CC, HPI 1-3 qualifiers (brief HPI)||1 system|
|99202 20||Straight||CC, HPI x 1-3, ROS x 1 system||2—4 systems|
|99203 30||Low||CC, HPI x 4, ROS x 2 systems, at least 1 Hx||5—7 systems|
|99204 45||Moderate||CC, HPI x 4, ROS x 10, PMFS (3 Hx)||8+ systems|
|99205 60||High||CC, HPI x 4, ROS x 10, PMFS (3 Hx)||8+ systems|
|99212 10||Straight||CC & HPI 1-3 qualifiers (brief HPI)||1 system|
|99213 15||Low||CC, HPI x 1-3, ROS x 1 system||2—4 systems|
|99214 25||Moderate||CC, HPI x 4 (or 3+ chronic diseases), ROS x 2 systems, PFSH (1 Hx)||5—7 systems|
|99215 40||High||CC, HPI x 4 (or 3+ chronic diseases), ROS x 10, PMFS (3 Hx)||8+ systems|
In these tables, MDM stands for medical decision making complexity, which takes into account the type of decision making, the number of possible diagnoses or management options to be considered, the extent of the data to be reviewed, and the risk associated with the condition.
CC stands for chief complaint. HPI stands for history of present illness. ROS stands for review of systems. PMFS stands for personal/medical/family/social history. The number for each represents the number of components or systems covered.
But when coding for time, what matters is the amount of time you spent with the patient, and that more than half of that time was spent in counseling or coordination of care.
Pertinent ICD10 codes
There are a host of diagnosis codes you can use to bill this vaccine counseling. Most of these codes are found in the Z28 family, Immunization not carried out and underimmunization status.
- Z28.0 Immunization not carried out because of contraindication
- Z28.01 Immunization not carried out because of acute illness of patient
- Z28.02 Immunization not carried out because of chronic illness or condition of patient
- Z28.03 Immunization not carried out because of immune compromised state of patient
- Z28.04 Immunization not carried out because of patient allergy to vaccine or component
- Z28.09 Immunization not carried out because of other contraindication
- Z28.1 Immunization not carried out because of patient decision for reasons of belief or group pressure
- Z28.2 Immunization not carried out because of patient decision for other and unspecified reason
- Z28.20 Immunization not carried out because of patient decision for unspecified reason
- Z28.21 Immunization not carried out because of patient refusal
- Z28.29 Immunization not carried out because of patient decision for other reason
- Z28.3 Underimmunization status
- Z28.8 Immunization not carried out for other reason
- Z28.81 Immunization not carried out due to patient having had the disease
- Z28.82 Immunization not carried out because of caregiver refusal
- Z28.83 Immunization not carried out due to unavailability of vaccine
- Z28.89 Immunization not carried out for other reason
- Z28.9 Immunization not carried out for unspecified reason
- Z71.9 Counseling, unspecified
- Z71.89 Other specified counseling
The Same-Day Conundrum
The remaining challenge is that many payers will not pay for an E&M code on the same day as a well child (preventive care) visit. That means if Julia comes in for a 2-year well child visit, and you spend 20 minutes just counseling on vaccines, in addition to the regular visit time, and her parents continue to decline the recommended vaccines, you are very unlikely to get paid for both 99392 for the preventive care visit and 99214 for the vaccine counseling, even if you use modifier 25 to indicate this was a “Significant, separately identifiable Evaluation and Management (E/M) by the same physician or other qualified health care professional on the same day of the procedure or other service.”
Counseling is unlikely to be considered separate because it is intended to be part of the preventive care visit. However, we have a lot of counseling to do on regular infant and child development, adjusting to new siblings, potty training, introducing solid foods, starting daycare, wearing helmets, eating vegetables, etc. The time that vaccine hesitancy requires vastly outstrips the limited time already allocated for all of the regular anticipatory guidance topics.
Given that the topic requires significant time, my suggestion is to arrange for a separate visit to discuss vaccine topics. If your organization supports telemedicine, this is an ideal use, especially since it can be easier to involve two parents on a telemedicine visit than to get two parents into an office visit, especially when one or both work outside the home, and each may have different concerns or different levels of concern about vaccines. In Washington State, telemedicine is required to be covered if the service would otherwise be covered in office.
I am not a certified coder, and this is not medical or legal advice. Consult with your own coding and billing team before changing your billing practices. The conversations you have with your patients and families about immunizations are valuable, and they should be coded in such a way that they can bring value to your organization as well.
Dayan GH, Ortega-Sánchez IR, LeBaron CW, Quinlisk MP; Iowa Measles Response Team. The cost of containing one case of measles: the economic impact on the public health infrastructure–Iowa, 2004. Pediatrics. 2005;116(1):e1–e4. doi:10.1542/peds.2004-2512
Note: this post was updated on 12/6/2019 to include additional reference information on billing for vaccine administration for pediatric Medicaid patients.